Earlier this year, California’s health benefit exchange marketplace, Covered California, exercised an option under its enabling legislation to standardize benefit designs for health plans sold on the exchange, consistent with its active purchaser role.

Pending legislation, SB 639, would require plans sold off the exchange marketplace to also employ standard benefit designs. (The measure would apply solely to managed care plans and not insurance products.) SB 639 would do so by adding California Health & Safety Code Section 1367.008 mandating standardized product designs for all managed care plan products at each of the metal tier actuarial value rating levels. It does so with language barring the sale of any product at each of the metal tier levels “unless it is a standardized product consistent with [Health & Safety Code] Section 1366.6.”

But therein lay a conflict. Section 1366.6(e) requires health care service plans not participating in the exchange “offer at least one standardized product that has been designated by the Exchange,” provided the Exchange exercises its authority to require standardized benefit designs. At least one obviously does not encompass all plans offered outside the exchange marketplace. (Emphasis added)

New Mexico is following Utah in having the federal government operate the individual side of its health benefit exchange marketplace while opting to run its own Small Business Health Options Program (SHOP).

The Associated Press reports state officials made the decision because there isn’t sufficient time to build the eligibility and enrollment system to serve the individual market segment for plan year 2014; the federal government will do so initially. New Mexico was one of the last states to decide whether to operate a state-based exchange marketplace.

Like this:

Health insurance agents and brokers nationwide worry that federally funded Assisters and exchange funded Navigators that help individuals and families sign up for health coverage offered through state exchange marketplaces will duplicate their own role. A top Nevada insurance regulator sought to put those fears to rest at an educational symposium this week hosted by the Northern Nevada chapter of the National Association of Health Underwriters (NAHU).

While state-certified assister personnel can assist people enroll in coverage sold on the state’s exchange marketplace, Nevada Health Link, they will not be permitted to help individuals and families select which plan is best for them.

Doing so is within scope of a producer license, noted Todd Rich, chief deputy commissioner of the Nevada Division of Insurance, who warned that regulators would “pull the ticket” of certified assister personnel found to be doing so. (Nevada has opted to have its Division of Insurance certify and oversee assister personnel). A primary enforcement method to ensure assisters operate within those boundaries: mystery shoppers.

A Blue Shield of California executive is urging California lawmakers in an op-ed article in today’s Sacramento Bee to close a loophole sanctioned by federal regulations that could front load the exchange marketplace with high cost individuals and families. That could leave plans participating in California’s exchange marketplace, Covered California, carrying an inequitable cost burden in the first year of its operation, asserts Janet Widmann, the health insurer’s executive vice president of markets. It would do so by allowing plans to elect to continue to operate into 2014 under current rules that allow plans to medically underwrite applicants and reject those with potentially costly medical conditions. Unless the loophole is closed, Widmann warns, all health plan issuers would be tempted to exploit it since they could still medically underwrite and select applicants for plans sold off the exchange marketplace so as to not initially end up with a disproportionate share of high cost insureds. Widmann explains:

Since these loophole policies will enroll only those who are healthy enough to obtain coverage under the current discriminatory system, policies that meet the requirements of the new law will be left to cover a disproportionate number of less healthy people. As a result, premiums for coverage offered through the insurance exchange will be significantly higher. Even insurers that have supported reform and want to see the exchange succeed will be pressured to sell the loophole policies to avoid losing healthy customers to competitors.

Plans sold in the Covered California marketplace would be unable to exploit the loophole under policy adopted by Covered California last week requiring qualified health plans with which it contracts to terminate plans they currently offer that are not compliant with the Affordable Care Act as of December 31, 2013. The “level playing field” provision is at section 3.04(b) of the Covered California QHP Model Contract:

(b) Contractor agrees that, to the extent not already required to do so by law, effective no later than December 31, 2013, it shall terminate or arrange for the termination of all of its non-grandfathered individual health insurance plan contracts or policies which are not compliant with the applicable provisions of the Affordable Care Act. Contractor agrees to promote ways to offer, market and sell or otherwise transition its current members into plans or policies which meet the applicable Affordable Care Act requirements. This obligation applies to all non-grandfathered individual insurance products in force or for sale by Contractor whether or not the individuals covered by such products are eligible for subsidies in the Exchange. All terminations made pursuant to this section shall be in accord with cancellation and nonrenewal provisions and notice requirements in California Health and Safety Code Section 1365, California Insurance Code Sections 10273.4, 10273.6 and 10713, and relevant state regulations and guidance.

Last week, California enacted two bills, ABX1-2 and SBX1-2, establishing 2014 market rules for the individual and small group markets and conforming state law to Affordable Care Act provisions. The measures did not include a provision that would close the loophole. Widmann suggests legislation mandating all non-grandfathered health plans (those not in effect when the Affordable Care Act was enacted in March 2010) play under the 2014 market rules barring medical underwriting of applicants. That would require new special session or urgency legislation that would take effect before the end of 2013.

Despite the assumption that California would opt to expand Medicaid eligibility to households with incomes between 100 and 133 percent of federal poverty guidelines as permitted under the Patient Protection and Affordable Care Act, the policy question remains open in the Golden State. A number of sticking points remain as detailed in this story in today’s Los Angeles Times. Chief among them is Gov. Jerry Brown’s expectation that since counties would benefit from the expansion through a reduced burden of caring for indigents not currently eligible for Medi-Cal as it’s called in California, they should help Sacramento shoulder the state’s future federal Medicaid cost share.

According to The Times, the Brown administration is also concerned that allowing people to enroll in Medi-Cal online could encourage fraud. California is rushing to ready an online enrollment system, the California Eligibility, Enrollment and Retention System (CALHEERS), to implement the Affordable Care Act’s mandate that individuals and families be offered enrollment for both government insurance programs like Medi-Cal and private coverage offered through its health benefit exchange thorough a single, streamlined application process. The unresolved policy question of whether to expand Medi-Cal eligibility poses significant potential to complicate an already complex process to prepare the online system and to provide enrollees what state officials expect to be a customer-friendly “no wrong door” experience. Problems integrating the state’s legacy Medi-Cal eligibility computer software with CALHEERs have already delayed plans to have it functional by the October 1 pre-enrollment date for 2014 coverage until January 1, 2014.

While the Brown administration’s concerns over expanding eligibility for Medi-Cal have stalled legislation that would do so, the administration is sponsoring pending legislation, SBX1-3, that would authorize commercial Medicaid managed care “bridge plans” per federal guidance issued in December, 2012 for those earning up to 200 percent of federal poverty. The plans would be available through the state’s exchange marketplace, Covered California.

Since the Affordable Care Act deems households with incomes of at least 100 percent of federal poverty eligible to buy coverage through the exchange marketplace, the bridge plan option provides policymakers an alternative to expanding Medi-Cal eligibility to 133 percent of federal poverty. Some states that have declined to expand Medicaid eligibility including Tennessee, Arkansas and Oklahoma are negotiating with the federal Center for Medicare and Medicaid Services to obtain waivers to allow their Medicaid eligibles to purchase commercial coverage on their exchanges. Absent a near term political agreement to expand Medi-Cal eligibility, California could soon be among them.

If the trend continues, it could lead to a bifurcated Medicaid system: basic, legacy Medicaid for those households with incomes below 100 percent of federal poverty guidelines and a “super Medicaid” system of federally subsidized coverage for households with incomes above the poverty line that wouldn’t otherwise qualify for Medicaid. It would also have fiscal implications for the states electing to “expand” Medicaid eligibility via Medicaid bridge plans sold on their health benefit exchange marketplaces since it would reduce their future federal Medicaid cost share burden, shifting subsidization fully to the federal government in the form of advance income tax credits.

Early this year, Utah received conditional approval to operate a state-based health insurance exchange marketplace from the federal government. The approval was somewhat surprising given the state’s insistence on operating only what amounted to a scaled down, online Small Business Health Options Program (SHOP) that it put in place before the 2010 enactment of the federal Patient Protection and Affordable Care Act. Utah’s Avenue H wouldn’t have met federal exchange requirements, primarily because it didn’t offer plans for individuals. The likely outcome would have been disapproval of Utah’s state-based exchange status and the feds taking over Utah’s exchange.

Under the terms of an agreement between the state and the federal government reported today by The Salt Lake Tribune, the feds will run the Utah’s individual exchange marketplace while the state will operate Avenue H as a state-run SHOP exchange. Avenue H will operate “without a competing SHOP exchange or interjection by the federal government” Gov. Gary R. Herbert wrote in a May 9, 2013 letter to U.S. Health and Human Services Secretary Kathleen Sebelius conveying his understanding of the deal.

The newspaper notes if the deal is approved as expected this week, Utah would be the only state exchange operating under such an arrangement:

The agreement is unique to Utah and essentially opens up a fourth alternative for operating the federally-mandated exchanges. Previously states had only three choices — a state-run exchange, a federally-run one, or a state-federal partnership exchange